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Systems of Care 3

NUR 4739

1. A nurse is reviewing laboratory results and notes that a clients serum sodium level is 150 mEq/L. The nurse reports the sodium level to the physician and the physician prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid?
a) peas b) cauliflower c) low-fat yogurt d) processed oat cereals D:The normal serum sodium level is 135 to 145 mEq/L. A serum sodium level of 150 mEq/L indicates hypernatremia. Based on this finding, the nurse would instruct the client to avoid foods high in sodium. Low-fat yogurt, cauliflower, and peas are good food sources of phosphorus. Processed foods are high in sodium content.

2. A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client? a) twitching b) negative Trousseau's sign c) hypoactive bowel sounds d) hypoactive deep tendon reflexes
A: Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseaus or Chvosteks sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

3. A nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and
a Pco2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? a) sodium level of 145 mEq/L b) potassium level of 3.0 mEq/L c) magnesium level of 2.0 mg/dL d) phosporus level of 4.0 mg/dL B: Clinical manifestations of respiratory alkalosis include headache, tachypnea, paresthesias, tetany, vertigo, convulsions, hypokalemia, and hypocalcemia. Options A, C, and D identify normal laboratory values. Option B identifies the presence of hypokalemia. 104. The nurse teaches skin care to the client receiving external radiation therapy. Which of the following statements, if made by the client, would indicate the need for further instruction? a) I will handle the area gently b) I will avoid the use of deodorants

Systems of Care 3
c) I will limit sun exposure to 1 hour daily d) I will wear loose-fitting clothing

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C - The client needs to be instructed to avoid exposure to the sun. Options A, B, and D are accurate measures in the care of a client receiving external radiation therapy. 91. A nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which of the following is an early sign of this oncological emergency? a) cyanosis b) arm edema c) periorbital edema d) mental status changes C - Superior vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and client complaints of tightness of a shirt or blouse collar. As the compression worsens the client experiences edema of the hands and arms. Mental status changes and cyanosis are late signs. 92. A nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer and tells the staff that which of the following is a serious late sign of this oncological emergency? a) headache b) dysphagia c) constipation d) electrocardiographic changes D - Hypercalcemia is a late manifestation of bone metastasis in late-stage cancer. Headache and dysphagia are not associated with hypercalcemia. Constipation may occur early in the process. Electrocardiogram changes include shortened ST segment and a widened T wave. 93. As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and selfcare during the period of the greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed when the client states: a) I should avoid blowing my nose b) I may need a platelet transfusion if my platelet count is too low c) I'm going to take aspirin for my headache as soon as I get home I will count the number of pads and tampons I use when menstruating C - During the period of greatest bone marrow suppression (the nadir), the platelet count may be low, less than 20,000 cells/mm3. Option C describes an incorrect statement by the client. Aspirin and nonsteroidal antiinflammatory drugs and products that contain aspirin should be avoided because of their antiplatelet activity, thus further teaching is needed. Options A, B, and D are correct statements by the client to prevent and monitor bleeding.

Systems of Care 3

NUR 4739

94. A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? Select all that apply a) radiation b) chemotherapy c) increased fluid intake d) serum sodium levels e) decreased oral sodium intake f) medication that is antagonistic to antidiuretic hormone A, B, D, F - Cancer is a common cause of syndrome of inappropriate antidiuretic hormone (SIADH). In SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. The syndrome is managed by treating the condition and cause and usually includes fluid restriction, increased sodium intake, and medication with a mechanism of action that is antagonistic to antidiuretic hormone. Sodium levels are monitored closely because hypernatremia can develop suddenly as a result of treatment. The immediate institution of appropriate cancer therapy, usually radiation or chemotherapy, can cause tumor regression so that antidiuretic hormone synthesis and release processes return to normal. 32. A nurse is caring for a client with an internal radiation implant. Which of the following instructions is appropriate? a) allow the client to go to the bathroom b) avoid creams and lotions c) visitors are allowed to stay in the room d) the client should remain in bed during the entire duration of treatment D - the client receiving internal radiation therapy should be on complete bed rest to prevent dislodgement of the implant. The client has 2-way foley catheter during the treatment. Choices B, C, and D indicate correct understanding of the patient on internal radiation therapy, and do not need intervention by the nurse. 34. The client is receiving internal radiation therapy. The nurse should a) remember to give the badge to the next-shift nurse b) maintain a 30-minute close contact with the patient in a shift c) wear gloves, mask and gown when entering the client's room d) instruct relatives no to visit the client during the entire duration of the treatment A - dosimeter badge is used to measure amount of exposure to radiation. It should be endorsed to the next shift 35. A nurse is assessing a client with metastatic breast cancer who reports nocturia, weakness, nausea and vomiting. The client's serum electrolytes include potassium 4.2 mEq/L, sodium 135 mEq/L, calcium 7.0 mEq/L, and magnesium 2.0 mEq/L. Based on the assessment findings, the priority action for the nurse is to: a) start client on fluid restriction b) administer calcium gluconate c) increase the client's IV fluids d) administer Allopurinol

Systems of Care 3

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C - nocturia, nausea and vomiting cause dehydration. Therefore, the correct nursing action is to increase the client's IV fluids. 28. Which of the following nursing diagnoses would rank as the most important in the planning of care for a client in two weeks after the chemotherapy has begun? a) potential for infection b) activity intolerance c) impaired skin integrity d) self-esteem disturbance A - chemotherapy causes immunosuppression. Therefore, the patient is at risk to develop infection. 29. During the administration of a chemotherapeutic drug, the nurse observes that there is a lack of blood return from the intravenous catheter. The priority action by the nurse would be to a) stop the administration of the drug immediately b) reposition the client's arm and continue with the administration of the drug c) apply a tourniquet to the patient's affected arm and notify the doctor d) continue to administer the drug and assess for edema at the IV site A - chemotherapeutic agents are irritating to tissues. Lack of blood return from the IV catheter indicates that it is out of vein. Therefore, administration of the drug should be stopped immediately. 21. Which of the following nursing actions is most appropriate when caring for a client with radium implant? a) wear gloves when entering the client's room b) wear masks and gloves when performing procedures to the client c) avoid staying with the client for more than 30 minutes in a shift d) place client's soiled gowns and linens in a plastic bag C - the nurse must limit her exposure to the client having internal radiation therapy to prevent contamination. The nurse must observe DTS (distance, time, and shielding). Time: 5 minutes/exposure; maximum of 30 minutes in an 8-hour shif

25. Which of the following statements when made by the client with leukemia indicates that the client understands the health teachings given by the nurse? Select all that apply a) I am allowed to eat raw foods b) I have to avoid raw fruits and vegetables c) fresh flowers should not be allowed in my room d) if I developed joint pains, I should apply cold compress to the area e) if I developed high fever, I should take aspirin f) I am allowed to watch baseball games g) I should use soft-bristled toothbrush

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B, C, D, G - indicates that the client with leukemia understands health teachings. A client with leukemia has low resistance to infection and bleeding tendencies. 12. The client is receiving internal radiation therapy. What is the appropriate nursing action to minimize radiation contamination? a) put the soiled linens in double bag b) keep clients things close to her bedside c) always wear gloves when entering the client's room d) minimize contact with the client D - Each contact with the client undergoing internal radiation therapy should last for 5 minutes only, a total of 30 minutes in an 8-hour shift, to minimize radiation contamination. The nurse should wear dosimeter badge to measure radiation exposure. 72. The client with leukemia is receiving busulfan (Myleran) and allupurinol (Zyloprim) is prescribed for the client. The nurse tells the client that the purpose of the allupurinol is to prevent: a) nausea b) alopecia c) vomiting d) hyperuricemia

D - Allopurinol decreases uric acid production and reduces uric acid concentrations in serum and urine. In the client receiving chemotherapy, uric acid levels increase as a result of the massive cell destruction that occurs from the chemotherapy. This medication prevents or treats hyperuricemia caused by chemotherapy. Allopurinol is not used to prevent alopecia, nausea, or vomiting.

73. The client receiving chemotherapy is experiencing mucositis. The nurse advises the client to use which of the following as the best substance to rinse the mouth? a) alcohol-based mouthwash b) hydrogen peroxide mixture c) lemon-flavored mouthwash d) weak salt and bicarbonate mouth rinse D - An acidic environment in the mouth is favorable for bacterial growth, particularly in an area already compromised from chemotherapy. Therefore, the client is advised to rinse the mouth before every meal and at bedtime with a weak salt and sodium bicarbonate mouth rinse. This lessens the growth of bacteria and limits plaque formation. The other substances are irritating to oral tissue. If hydrogen peroxide must be used because of severe plaque, it should be a weak solution because it dries the mucous membranes. 66.When assessing the laboratory results of the client with bladder cancer and bone metastasis, the nurse notes a calcium level of 12 mg/dl. The nurse recognizes that this is consistent with which oncological emergency? a) hyperkalemia

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b) hypercalemia c) spinal cord compression d) superior vena cava syndrome

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B - Hypercalcemia is a serum calcium level higher than 10 mg/dL, most often occurs in clients who have bone metastasis, and is a late manifestation of extensive malignancy. The presence of cancer in the bone causes the bone to release calcium into the bloodstream. 61. The home health care nurse is caring for a client with cancer and the client is complaining of acute pain. The appropriate nursing assessment of the client's pain would include which of the following? a) the client's pain rating b) nonverbal cues from the client c) the nurse's impression of the client's pain d) pain relief after appropriate nursing intervention A - The clients self-report is a critical component of pain assessment. The nurse should ask the client about the description of the pain and listen carefully to the clients words used to describe the pain. The nurses impression of the clients pain is not appropriate in determining the clients level of pain. Nonverbal cues from the client are important but are not the most appropriate pain assessment measure. Assessing pain relief is an important measure, but this option is not related to the subject of the question. 58. The client is hospitalized for insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. The initial action by the nurse is to: a) call the physician b) reinsert the implant into the vagina immediately c) pick up the implant with gloved hands and flush it down the toilet d) pick up the implant with long-handled forceps and place it in a lead container D - A lead container and long-handled forceps should be kept in the clients room at all times during internal radiation therapy. If the implant becomes dislodged, the nurse should pick up the implant with long-handled forceps and place it in the lead container. Options A, B, and C are inaccurate interventions. 59. The nurse is caring for a client experiencing neutropenia as a result of chemotherapy and develops a plan of care for the client. The nurse plants to: a) restrict all visitors b) restrict fluid intake c) teach the client and family about the need for hand hygiene d) insert an indwelling urinary catheter to prevent skin breakdown C - In the neutropenic client, meticulous hand hygiene education is implemented for the client, family, visitors, and staff. Not all visitors are restricted, but the client is protected from persons with known infections. Fluids should be encouraged. Invasive measures such as an indwelling urinary catheter should be avoided to prevent infections 60. The nurse is reviewing the laboratory results of a client receiving chemotherapy whose platelet count is

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10,000 cells/mm3. based on this laboratory value, the priority nursing assessment is which of the following? a) assess skin turgor b) assess temperature c) assess bowel sounds d) assess level of consciousness D - A high risk of hemorrhage exists when the platelet count is less than 20,000 cells/mm3. Fatal central nervous system hemorrhage or massive gastrointestinal hemorrhage can occur when the platelet count is less than 10,000 cells/mm3. The client should be assessed for changes in level of consciousness, which may be an early indication of an intracranial hemorrhage. Option B is a priority nursing assessment when the white blood cell count is low and the client is at risk for an infection. Although options A and C are important to assess, they are not the priority in this situation. 47. The client with cancer is receiving chemotherapy and develops thrombocytopenia. The nurse identifies which intervention as the highest priority in the nursing plan of care? a) monitoring temperature b) ambulation three times daily c) monitoring the platelet count d) monitoring for pathological fractures C - Thrombocytopenia indicates a decrease in the number of platelets in the circulating blood. A major concern is monitoring for and preventing bleeding. Option A relates to monitoring for infection, particularly if leukopenia is present. Options B and D, although important in the plan of care, are not related directly to thrombocytopenia. 48. The nurse is monitoring the laboratory results of a client preparing to receive chemotherapy. The nurse determines that the white blood cell count is normal if which of the following results were present? a) 2000 to 5000 cells/mm3 b) 3000 to 8000 cells/mm3 c) 5000 to 10000 cells/mm3 d) 7000 to 15000 cells/mm3 C - The normal white blood cell count ranges from 5000 to 10,000 cells/mm3. Options A and B indicate low values. Option D indicates an elevated value. 42. The client is undergoing radiation therapy to treat lung cancer. Following treatment, the nurse notes erythema on the client's chest and neck, and the client is complaining of pain at the radiation site. The nurse interprets this assessment data a(n): a) allergic reaction to the radiation b) superficial injury to tissue from the radiation c) cutaneous reaction to products formed by the lysis of the neoplastic cells d) ischemic injury, much like pressure ulcer formation. caused by pressure from the linear accelerator B

Systems of Care 3

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- Superficial injury from radiation can manifest with erythema (probably caused by capillary damage), hyperpigmentation (from stimulation of melanocytes), dry desquamation (caused by basal cell destruction), or moist desquamation (also caused by basal cell destruction). Moist desquamation is comparable to a seconddegree burn in histology, appearance, and sensation. 44. The client is diagnosed as having a bowel tumor and several diagnostic tests are prescribed. The nurse understands that which test will confirm the diagnosis of malignancy? a) biopsy of tumor b) abdominal ultrasound c) magnetic resonance imaging d) computed tomography scan A -A biopsy is done to determine whether a tumor is malignant or benign. Magnetic resonance imaging, computed tomography scan, and ultrasound will visualize the presence of a mass but will not confirm a diagnosis of malignancy.

39. The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which of the following? a) 2,000 cells/mm3 b) 5,800 cells/mm3 c) 8,400 cells/mm3 d) 11,500 cells/mm3 A - the normal white blood cell count ranges from 4,500 to 11,000/mm3. The client who is immunosuppressed has a decrease in the number of circulating white blood cells. The nurse implements neutropenic precautions when the client's values fall sufficiency below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy. Options B, C, and D are normal values. 46. A client with acquired immunodeficiency syndrome (AIDS) has a nursing diagnosis of Imbalanced nutrition: less than body requirements. The nurse plans which of the following goals with this client? a) consume foods and beverages that are high in glucose b) plan large menus and cook meals in advance c) eat low-calorie snacks between meals d) eat small, frequent meals throughout the day D - The client should eat small, frequent meals throughout the day. The client also should take in nutrient-dense and high-calorie meals and snacks rather than those that are high in glucose only. The client is encouraged to eat favorite foods to keep intake up and plan meals that are easy to prepare. The client can also avoid taking fluids with meals to increase food intake before satiety sets in.

47. A client with acquired immunodeficiency syndrome (AIDS) is experiencing shortness of breath related to Pneumocystis jiroveci pneumonia. Which measure should the nurse include in the plan of care to assist the client in performing activities of daily living? a) provide supportive care with hygiene needs

Systems of Care 3
b) provide meals and snacks with high-protein, high calorie, and high-nutritional value c) provide small, frequent meals d) offer low microbial foods

NUR 4739

A - Providing supportive care with hygiene needs as needed reduces the client's physical and emotional energy demands and conserves energy resources for other functions such as breathing. Options B, C, and D are important interventions for the client with AIDS but do not address the subject of activities of daily living. Option B will assist the client in maintaining appropriate weight and proper nutrition. Option C will assist the client in tolerating meals better. Option D will decrease the client's risk of infection. 48. A client who was tested for human immunodeficiency virus (HIV) after a recent exposure had a negative result. During the post-test counseling session, the nurse tells the client which of the following? a) the test should be repeated in 6 months b) this ensures that the client is not infected with the HIV virus c) the client no longer needs to protect himself from sexual partners d) the client probably has immunity to the acquired immunodeficiency virus A - A negative test result indicates that no HIV antibodies were detected in the blood sample. A repeated test in 6 months is recommended because false-negative test results have occurred early in the infection. Options B, C, and D are incorrect. 49. A client is diagnosed with late stage human immunodeficiency virus (HIV), and the client and family are extremely upset about the diagnosis. The priority psychosocial nursing intervention for the client and family is to: a) tell the client and family to stop smoking because it will predispose the client to respiratory infections b) tell the client and family that raw or improperly washed foods can produce microbes c) encourage the client and family to discuss their feelings about the disease d) advise the client to avoid becoming pregnant because of the risk of transmission of the infection C - The priority psychosocial nursing intervention for the client and family is to encourage the client and family to discuss their feelings about the disease. Options A, B, and D identify physiological not psychosocial concerns. 50. A client is diagnosed with human immunodeficiency virus (HIV) infection. The nurse prepares a care plan for the client, knowing that HIV is primarily a condition in which: a) immunosuppression occurs and is indicated by a T4 lymphocyte count of less than 200/mm3 b) bacterial infection occurs, causing weakness c) fungal infection occurs, causing a rash and pruritus d) protozoan infection occurs, causing a fever and nonproductive cough A - HIV infection causes immunosuppression and is indicated by a T4 lymphocyte count of less than 200/mm3. Although bacterial, fungal, and protozoal infection can occur, these occur as opportunistic infections as a result of the immunosuppression. 41. A nurse is monitoring a client with herpes simplex virus who is receiving intravenous (IV) acyclovir (Zovorax). Which of the following laboratory results would be of concern as a possible adverse effect of this medication?

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a) blood urea nitrogen (BUN) of 36 mg/dL b) platelet count of 300,000 cells/mm3 c) white blood cell count of 6000 cells/mm3 d) red blood cell count of 5.2 million cells/mm3

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A - Although the most common adverse reactions with this medication are phlebitis and inflammation at the IV site, reversible nephrotoxicity evidenced by an elevated serum creatinine and BUN levels can occur in some clients. The cause of nephrotoxicity is deposition of acyclovir in the renal tubules. The risk of renal injury is increased by dehydration and by the use of other nephrotoxic medications. The values identified in options B, C, and D are within normal limits. 45. A client is receiving zalcitabine (Hivid). The nurse plans to monitor the results of which study to determine the effectiveness of this medication? a) enzyme-linked immunosorbent assay (ELISA) b) western blot c) CD4+ cell count d) complete blood cell (CBC) count with differential C - Zalcitabine slows the progression of acquired immunodeficiency syndrome (AIDS) by improving the CD4+ cell count. A CBC with differential may be done as part of an ongoing monitoring of the status of the client with AIDS, and to detect adverse effects of other medications. The ELISA and the Western blot are performed to diagnose AIDS initially. 33. The nurse is caring for a post-renal transplantation client taking cyclosporin (Sandimmune, Gengraf, Neoral). Th nurse notes an increase in one of he client's vital signs and the client is complaining of a headache. What is the vital sign that is most likely increased? a) pulse b) respiration c) blood pressure d) pulse oximetry C - Hypertension can occur in a client taking cyclosporine (Sandimmune, Gengraf, Neoral) and, because this client is also complaining of a headache, the blood pressure is the vital sign to be monitoring most closely. Other adverse effects include infection, nephrotoxicity, and hirsutism. Options A, B, and D are unrelated to the use of this medication. 21. The home care nurse is ordering dressing supplies for a client who has an allergy to latex. The nurse asks the medical supply personnel to deliver which of the following? a) elastic bandages b) adhesive bandages c) brown ace bandages d) cotton pads and silk tape D - Cotton pads and plastic or silk tape are latex-free products. The items identified in options A, B, and C are products that contain latex.

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24. Select the interventions that would apply in the care of a client at high risk for an allergic response to a latex allergy. Select all that apply a) use non-latex gloves b) use medications from glass ampules c) place the client in a private room only d) do not puncture rubber stoppers with needles e) keep a latex-safe supply cart available in the client's area f) use a blood pressure cuff from an electronic device only to measure the blood pressure A, B, D, E - If a client is allergic to latex and is at high risk for an allergic response, the nurse would use nonlatex gloves and latex-safe supplies, and would keep a latex-safe supply cart available in the clients area. Any supplies or materials that contain latex would be avoided. These include blood pressure cuffs, medications with a rubber stopper that requires puncture with a needle, latex-safe syringes, and latex-safe intravenous tubing. It is not necessary to place the client in a private room. 18. The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is at most risk for developing this type of allergy? a) hairdressers b) the homeless c) children in day care centers d) individuals living in a group home A - Individuals at risk for developing a latex allergy include health care workers, individuals who work in the rubber industry or those who have had multiple surgeries, have spina bifida, wear gloves frequently, such as food handlers, hairdressers, and auto mechanics, or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts. 19. The home care nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors associated with the allergy, the nurse questions the client about an allergy to which food item? a) eggs b) milk c) yogurt d) bananas D - Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts are at risk for developing a latex allergy. This is thought to be to the result of a possible cross-reaction between the food and the latex allergen. Options A, B, and C are unrelated to latex allergy. 20. The home care nurse is assigned to visit a client who has returned home from the emergency room following treatment for a sprained ankle. The nurse notes that the client as sent home with crutches that have rubber axillary pads and needs instructions regarding crutch walking. On admission assessment, the nurse discovers that the client has an allergy to latex. Before providing instructions regarding crutch walking, the nurse should: a) contact the physician

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b) cover the crutch pads with cloth c) call the local medical supply store and ask for a cane to be delivered d) tell the client that the crutches must be removed from the house immediately

NUR 4739

B - The rubber pads used on crutches may contain latex. If the client requires the use of crutches, the nurse can cover the pads with a cloth to prevent cutaneous contact. Option 4 is inappropriate and may alarm the client. The nurse cannot order a cane for a client. Additionally, this type of assistive device may not be appropriate, considering this clients injury. No reason exists to contact the physician at this time. 14. A client calls the nurse in the emergency room and tells the nurse that he was just stung by a bee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. The appropriate nursing action is to: a) advise the client to soak the site in hydrogen peroxide b) ask the client if ever sustained a bee sting in the past c) tell the client to call an ambulance for transport to the emergency room d) tell the client no to worry about the sting unless difficulty with breathing occurs B - In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. The appropriate action, therefore, would be to ask the client if he ever received a bee sting in the past. Option A is not appropriate advice. Option C is unnecessary. The client should not be told not to worry. 15. The nurse is assisting in administering immunizations at a health care clinic. The nurse understands that an immunization will provide: a) protection from all disease b) innate immunity from disease c) natural immunity from disease d) acquired immunity from disease )D - Acquired immunity can occur by receiving an immunization that causes antibodies to a specific pathogen to form. Natural (innate) immunity is present at birth. No immunization protects the client from all diseases. 6. Which of the following individuals is least likely at risk for the development of Kaposis's sarcoma? a) A kidney transplant client b) a male with a history of same-gender partners c) a client receiving anti-neoplastic medications d) an individual working in an environment in which he or she is exposed to asbestos D - Kaposis sarcoma is a vascular malignancy that presents as a skin disorder and is a common acqu ired immunodeficiency syndrome indicator. Malignancy is seen most frequently in men with a history of samegender partners. Although the cause of Kaposis sarcoma is not known, it is considered to be caused by an alteration or failure in the immune system. The renal transplantation client and the client receiving antineoplastic medications are at risk for immunosuppression. Exposure to asbestos is not related to the development of Kaposis sarcoma. 7. The nurse prepares to give a bath and change the bed linens on a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which of the following would the

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nurse incorporate into the plan during the bathing of this client? a) wearing gloves b) wearing a gown and gloves c) wearing a gown, gloves, and a mask d) wear a gown and gloves to change the bed linens and gloves only for the bath

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B - Gowns and gloves are required if the nurse anticipates contact with soiled items such as those with wound drainage or is caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn. 10. The client with acquired immunodeficiency syndrome has raised, dark purplish-colored lesions on the trunk of the body. The nurse anticipates that which of the following procedures will be done to confirm whether these lesions are caused by Kaposi's sarcoma? a) skin biopsy b) lung biopsy c) western blot d) enzyme-linked immunosorbent assay A - The skin biopsy is the procedure of choice to diagnose Kaposis sarcoma, which frequently complicates the clinical picture of the client with acquired immunodeficiency syndrome. Lung biopsy would confirm Pneumocystis jiroveci infection. The enzyme-linked immunosorbent assay and Western blot are tests to diagnose human immunodeficiency virus status. 1. An older adult with no known cognitive impairment residing in a long-term care facility suddenly becomes disoriented and confused. There are no signs of extremity weakness or other neurological changes. Based on these observations, the nurse would focus the assessment in which priority body systems? a) pulmonary and renal systems b) reproductive and endocrine system c) integumentary and neurological systems d) cardiovascular and gastrointestinal systems A - Changes in mental status and confusion are commonly associated with infections in the older adult. Assessments of the pulmonary and renal systems would be the priority. The older adult is at risk for pneumonia. The lungs should be auscultated for decreased breath sounds and other adventitious sounds. Urinary tract infections are also common in older adults, especially women. Flank pain with frequency and urgency are symptoms. The urine should be monitored for cloudiness, odor, and other changes indicating hematuria. Based on the data in the question, the body systems identified in options B, C, and D are not the priority. 5. The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which of the following? a) swelling in the genital area b) swelling in the lower extremities c) punch biopsy of the cutaneous lesions d) appearance of reddish-blue lesions noted on the skin

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C - Kaposis sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.

18. A clinic nurse instructs the mother of a child with sickle cell anemia about the precipitating factors related to pain crisis. Which of the following, if identified by the mother as a precipitating factor, indicates the need for further instructions? a) stress b) trauma c) infection d) fluid overload D - Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The mother of a child with sickle cell disease should encourage fluid intake of 1 to 2 times the daily requirement to prevent dehydration. 19. A 10-year old child with hemophilia A has slipped on the ice and bumped his knee. The nurse should prepare to administer an: a) injection of factor X b) intravenous infusion of factor VIII c) intravenous infusion of croprecipitate d) intravenous infusion of desmopressin (DDAVP) B - Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. The primary treatment is replacement of the missing clotting factor; additional medications, such as those to relieve pain, may be prescribed depending on the source of bleeding from the disorder. A child with hemophilia A will be at risk for joint bleeding after a fall. Factor VIII will be prescribed intravenously to replace the missing clotting factor and minimize the bleeding. Desmopressin (DDAVP) is used to stimulate production of factor VIII, but it is not given intravenously. Factor X and cryoprecipitate are not used for clients with hemophilia A. 20. Laboratory studies are performed for a child suspected of having iron deficiency anemia. The nurse reviews the laboratory results, knowing that which of the following results would indicate this type of anemia? a) an elevated hemoglobin level b) a decreased reticulocyte count c) an elevated red blood cell count d) red blood cells are microcytic and hypochromic D - Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Results of tests that measure platelet function are normal; results of tests that measure clotting factor function may be abnormal. Therefore, abnormal laboratory results in hemophilia indicate a prolonged partial thromboplastin time. The platelet count, hemoglobin level, and hematocrit level are normal in hemophilia.

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21. A nurse analyzes the laboratory results of a child wiht hemophilia. The nurse understands that which of the following would most likely be abnormal in this child? a) platelet count b) hematocrit level c) hemoglobin level d) partial thromboplastin time D - Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Results of tests that measure platelet function are normal; results of tests that measure clotting factor function may be abnormal. Therefore, abnormal laboratory results in hemophilia indicate a prolonged partial thromboplastin time. The platelet count, hemoglobin level, and hematocrit level are normal in hemophilia. 23. A nurse is receiving a physician's orders for a child with sickle cell anemia who was admitted to the hospital for the treatment of vasoocclusive crisis. Which orders documented in the child's record should the nurse question? Select all that apply a) restrict fluid intake b) position for comfort c) avoid strain on painful joints d) apply nasal oxygen at 12L/min e) provide a high-calorie, high-protein diet f) give meperidine (Demerol), 25 mg IV, every 4 hours for pain A, C - Sickle cell anemia is a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell; insufficient oxygen causes the cells to assume a sickle shape and the cells become rigid and clumped together, obstructing capillary blood flow. Therefore, oral and intravenous fluids are an important part of treatment. Meperidine (Demerol) is not recommended for the child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. The nurse would thus question the order for restricted fluids and meperidine for pain control. Positioning for comfort, avoiding strain in painful joints, oxygen, and a high-calorie, high-protein diet are also important parts of the treatment plan. 25. The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 20,000/L. Based on this laboratory result, which intervention will the nurse document in the plan of care? a) monitor closely for signs of infection b) monitor the temperature every 4 hours c) initiate protective isolation precautions d) use a soft small toothbrush for mouth care D - If a child is severely thrombocytopenic and has a platelet count less than 20,000/L, bleeding precautions need to be initiated because of the increased risk of bleeding or hemorrhage. The precautions include limiting

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Systems of Care 3

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activity that could result in head injury, using soft toothbrushes or Toothettes, checking urine and stools for blood, and administering stool softeners to prevent straining with constipation. In addition, suppositories and rectal temperatures are avoided. Options A, B, and C are related to the prevention of infection rather than bleeding. 3. Which of the following laboratory findings support the diagnosis of disseminated intravascular coagulopathy (DIC)? a) elevated factor assays (II, V, and VII) b) increased platelet count c) elevated RBC, WBC, platelets d) prolonged prothrombin time and partial thromboplastin time D - DIC - is body's response to overstimulation of clotting and articulating processes in response to injury or disease. In DIC, bleeding occurs due to depletion of platelets in the general circulation which is due to massive blood clotting (decreased fibrinogen, increased protime, increased PTT, decreased platelets).

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